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County <br /> Safety and Buildings Division Dane <br /> t 11$ 201 W.Washington Ave.,P.O. Box 7162 Sanitary Permit Number(to be filled in by CCoo.� <br /> S Madison,WI 53707-7162 <br /> (32O(5— )d37 _ <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information ou rovide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m).Slats. f E E D S I L V i .s.e ELL I.�A D <br /> I. Application Information-Please Print All Information C 1, /V <br /> Property Owner's Name Parcel# <br /> IAR E.C VI-1 MAP ISc44 LLC FEB 19 2015 0''703-- 203- (aIO0- p <br /> Property Owner's Mailing Address Property Location <br /> Public Health MDC <br /> b0 I SOt,t i M . ouji■I k. D e iv E Environmental Health Govt.Lot <br /> City,State ' Zip Code Phone Number <br /> IkD1 SOIL 1 5E '/, SIA/ /, Section Zd <br /> II.Type of Building(check all that ap l T '7 N; R S E <br /> apply) : Lot <br /> �{l or2 Family Dwelling-Number of Bedr ms 5 I 0 Subdivision Name <br /> / 11I <br /> Block# Sp itta Name <br /> E"t tJl.l.Qom/ <br /> ❑Public/Commercial-Describe Use - -- <br /> ❑City of <br /> ['State Owned-Describe Use CSM Number ❑Village of // <br /> [Town of IV(1 DO OF T Z)NJ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ®New System Re Replacement System❑ p y ❑1'reatmenf/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ['Change of Plumber List Previous Permit Number and Date Issued <br /> g ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> &Non-Pressurized In-Ground ['Pressurized In-Ground ['At-Grade ❑Mound>24 in.of suitable soil ['Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation I Of,I)1 t)Q,Of t <br /> 75b , ta 1 (475 1 % '10 loo 7f Jo0.'S') fop.3' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units . e o v u <br /> New Tanks ' Existing Tanks 8 - - <br /> .8 R <br /> a.0 'v5 rn iZ(7 C- <br /> Seplic or Holding Tank <br /> ILO 50 (�5o a- µE 1: ' ✓� <br /> Dosing Chamber �p <br /> WO PaoO I ME-Anl S( <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Andrew W Melnholz -t,r‘. W. i'"r.J, 220165 I 608-831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 - - <br /> ---• ---., <br /> VIII.County/Department Use Only -..• - <br /> 4 <br /> Pe r' e Date Issued Issuing Agent i_ attire❑Disapproved a / `^°t /s <br /> ❑Owner Given Reason for Denial <br /> IX.'nConditioV of Approval/ReCasolns for Disapproval ` - —w._ ._.. ... . ._... , ._.___.. ,.-_:_. <br /> I <br /> I <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 112 x 11 inches in she <br /> SBD-6398(R. 11/11) <br />